News and Views on Social Marketing and Social Change

How do gossip and viral marketing play out in teddy bear clinics and with city rangers talking about wild boar? Do these approaches also reduce fear associated with hospital visits? In the next International Social Marketing Association (iSMA) webinar, Swiss social marketer Maurice Codourey sums up his research findings and many presentations at international congresses. He will also address the effectiveness of non-medical public presentations, constructivist didactics and municipal intelligence. Maurice works in innovative health care in Switzerland, lectures on social marketing at the EB School in Zurich, and is also a visiting professor at the West Pomeranian University of Technology Szczecin in Poland. He is the President of the Swiss Association of Communication and Marketing of Public Health and a Founding Member of the European Social Marketing Association.

I’ve signed up for one of the sessions on Wednesday, 17 September 2014. You can too. Two separate, live presentations are scheduled to accommodate global time zone differences. Go to the iSMA site for more information and to register.

This June I was honored to receive the Phillip Kotler Social Marketing Distinguished Service Award, “The Kotler Glass,” at the Social Marketing Conference in Clearwater Beach, FL. In his presentation of the award, Dr. Kotler noted that “[Craig] is known for many things; a prolific writer, a creative architect of programs, an innovator and risk taker, and an outspoken and long-time guiding force in our field…In fact, if one word could be used to describe him, catalyst is the perfect one. He is that agent that provokes significant change… For those who know him, he is a brilliant and courageous innovator that has provided the field with enough insight to last the rest of us for a lifetime.”

After receiving The Kotler Glass I took the opportunity to talk about happiness and well-being. The video of the talk was just completed (thanks to Eric Weaver!) and is embedded below [or use that last link].

I started with where I left off in my book, Social Marketing and Social Change, suggesting several opportunities for the future of social marketing. One of them concerned happiness or well-being.

How the deliberate use of social marketing could lead to positive change in personal subjective well being and national happiness indicators through increasing perceived and actual freedoms and tolerance is an area ripe for exploration; it could invite the discipline into global policy discussions and debates—and one could rightfully inquire, Are we back to asking, “can we sell brotherhood like soap?” (Wiebe, 1951). Perhaps. But now we have the benefit of sixty more years of experience to draw upon (p. 498).

Bhutan has recognized the supremacy of national happiness over national income since the early 1970s. It has famously adopted the goal of gross national happiness over gross national product (GNP). Such thinking is now gaining traction in other regions.

Costa Rica is well-known for being the greenest country in the world — an example of holistic and environmentally responsible development. Compared to other countries with similar income levels, it ranks higher in human development and is a beacon of peace and democracy. In the United Kingdom, statistical authorities are experimenting with National Well-being. The European Commission has its GDP and Beyond project. One of the overarching targets of the European Health 2020 policy is how to set targets for well-being. Quality of Life and Well-Being are foundational health measures of Healthy People 2020.

● Life evaluation – a reflective assessment on a person’s life or some specific aspect of it.

● Affect – a person’s feelings or emotional states, typically measured with reference to a particular point in time.

● Eudaimonia – a sense of meaning and purpose in life, or good psychological functioning (you can also take a look at the OECD Better Life Index).

Also noteworthy is that the Center for Disease Control and Prevention (CDC) has developed and validated a well-being index. Happiness and well-being are becoming mainstream topics in public policy, economic and, yes, public health circles. It is time for social marketing to be at that table.

A few months ago the International Day of Happiness came onto my radar screen. It is an international observance brought into being by a resolution of the United Nations General Assembly. The resolution in its entirety reads:

Recalling its resolution 65/309 of 19 July 2011, which invites Member States to pursue the elaboration of additional measures that better capture the importance of the pursuit of happiness and well-being in development with a view to guiding their public policies,

Conscious that the pursuit of happiness is a fundamental human goal,

Recognizing the relevance of happiness and well-being as universal goals and aspirations in the lives of human beings around the world and the importance of their recognition in public policy objectives,

Recognizing also the need for a more inclusive, equitable and balanced approach to economic growth that promotes sustainable development, poverty eradication, happiness and the well-being of all peoples,

Decides to proclaim 20 March the International Day of Happiness

Concomitant with this action, two World Happiness Reports have been issued. The 2013 report states that “Happiness is an aspiration of every human being, and can also be a measure of social progress.”

In a review of the research on the topic from around the world, the authors conclude that six key variables explain three-quarters of the variation in annual national happiness or well-being average scores over time and among over 150 countries. These six factors include: real GDP per capita, healthy life expectancy, having someone to count on, perceived freedom to make life choices, freedom from corruption, and generosity.

“In conclusion, there is now a rising worldwide demand that policy be more closely aligned with what really matters to people as they themselves characterize their lives.”

Many cities and other organizations created videos for the International Day of Happiness in 2014, all of them using the song "Happy" by Pharrell Williams as the soundtrack. One of my favorites is from Paris (over 2.6 million views when I posted this), though it was a little long for the conference. There are hundreds of these videos on YouTube to choose from. I chose one from Tel Aviv. The version that appears in the video is produced by students at the University of South Florida. Since they labored to edit and put the video together, and I am on the faculty there, why not? The idea is the same - user generated content around a social object.

At the end of the video I called for social marketing to take a lead role in taking International Day of Happiness to a new level. It’s time we showed the world that marketing can, indeed, be used to improve people’s well-being (or happiness) and make the world a better place.

Stay tuned for more… and let me know how you can help make this happen in your corner of the universe.

Segmentation is one of the first critical decisions a social marketing or health communication program must make - even if it is to not segment and use the 'field of dreams' strategy ("If we build it, they will come"). Even when decisions are made to identify and focus on priority segments of the population, many segmentation approaches end up being used for no more than directions for casting calls and art directors ("We need to have one of these types and another of these types").

"...the purpose of segmentation is not to answer the question of whether we can distinguish different subgroups of a larger population. The question for segmentation is whether identifying differences among groups will drive how we approach our marketing solution. That is, does it make sense to have different behaviors, messages, products, and services aimed at specific subgroups of people? Or are there certain common characteristics that supersede these distinctions? And just as important, if we do uncover such differences, do we have the resources to develop the specific marketing mixes each group deserves?" (p. 133)

Too many programs, maybe even yours (?), conduct segmentation research and analysis and then proceed to design one intervention to serve multiple groups. That is not good practice. Other efforts are more academic in nature, and seek to understand what characteristics distinguish different segments from each other, but offer few insights into what those differences mean for marketing and communications (other than broadening or narrowing the casting call).

There are people who will argue with you that segmentation goes against the grain of trying to serve everyone. You might counter these opinions by referring to a recent study that examined the ethical dimensions of segmentation and found there is more potential harm from not segmenting - specifically that mass approaches (or "one size fits all") can actually deepen disparities among population groups (a point Dick Manoff also made many years ago).

Social marketers should always be on the lookout for new ideas about changing behaviors. This is the reason I spend time talking about different theories and models of behavior change. In workshops that I facilitate, I use this slide to illustrate some of the main ideas from some usual, and not so typical, theories that I find are employed by many social change agents.

These ideas guide how we think about a puzzle, seek to understand it and then solve it. What dramatically illustrates the power of a theory, and its drawbacks, is to break the workshop (or class) into five smaller groups. All of the groups are given the same behavior change challenge and asked to come up with one or more priority groups to focus on, what research questions they would want to ask of them to learn more about the problem, and what potential solutions can they quickly generate (brainstorm). But each group must use only the 5-6 concepts for the theory they are assigned. After just 15-20 minutes of working up an approach, the divergence among the five groups in who they select for a priority group, the types of research questions they would pose, and the elements of their proposed interventions makes a strong experience of 'what we know is what we see.' For example, if all you know is Stages of Change, then every puzzle you confront boils down to classifying and moving people from Precontemplators to Contemplators to Actors. Unfortunately, as many of you have no doubt discovered, all of the health and social puzzles we tackle rarely conform to one theoretical model. A primary source of failure of interventions is the use of the wrong theory to understand and address the puzzle.

Behavioral economics is one domain that has captured the interest of policy-makers and social marketers alike. It has some unique ideas about decision-making (mostly that they aren't completely 'rational' and cognitive biases cloud many of our judgments), and liberally borrows from social-psychological approaches to behavior change. In truth, it is never advanced by its supporters as a' 'theory of change' as much as a useful framework to think differently about designing solutions to wicked problems.

One behavioral economics framework I have discussed is MINDSPACE, and it is included in my book as one of the ways to think about wicked problems. The creators of MINDSPACE, the Behavioural Insights Team (formerly the Behavioural Insights Unit), have recently published a new report in which they admit that the nine elements were difficult for policy-makers to keep in mind when developing alternative solutions to their puzzles. So they have now boiled it down to a simpler mnemonic - EAST (Easy, Attractive, Social and Timely). You can read more about the model in EAST-Four simple ways to apply behavioral insights. But for a quick overview, here is the model as they describe it in the Executive Summary.

1. Make it Easy

Harness the power of defaults. We have a strong tendency to go with the default or pre-set option, since it is easy to do so. Making an option the default makes it more likely to be adopted.

Reduce the ‘hassle factor’ of taking up a service. The effort required to perform an action often puts people off. Reducing the effort required can increase uptake or response rates.

Simplify messages. Making the message clear often results in a significant increase in response rates to communications. In particular, it’s useful to identify how a complex goal can be broken down into simpler, easier actions.

2. Make it Attractive

Attract attention. We are more likely to do something that our attention is drawn towards. Ways of doing this include the use of images, colour or personalisation.

Design rewards and sanctions for maximum effect. Financial incentives are often highly effective, but alternative incentive designs — such as lotteries — also work well and often cost less.

3. Make it Social

Show that most people perform the desired behaviour. Describing what most people do in a particular situation encourages others to do the same. Similarly, policy makers should be wary of inadvertently reinforcing a problematic behaviour by emphasising its high prevalence.

Use the power of networks. We are embedded in a network of social relationships, and those we come into contact with shape our actions. Governments can foster networks to enable collective action, provide mutual support, and encourage behaviours to spread peer-to-peer.

Encourage people to make a commitment to others. We often use commitment devices to voluntarily ‘lock ourselves’ into doing something in advance. The social nature of these commitments is often crucial.

4. Make it Timely

Prompt people when they are likely to be most receptive. The same offer made at different times can have drastically different levels of success.

Behaviour is generally easier to change when habits are already disrupted, such as around major life events.

Consider the immediate costs and benefits. We are more influenced by costs and benefits that take effect immediately than those delivered later. Policy makers should consider whether the immediate costs or benefits can be adjusted (even slightly), given that they are so influential.

Help people plan their response to events. There is a substantial gap between intentions and actual behaviour. A proven solution is to prompt people to identify the barriers to action, and develop a specific plan to address them.

Some of these ideas may sound familiar to you. You might also note that none of these methods have direct counterparts to any of the variables in the theories I presented above. [Try this exercise: add a sixth column to the table of theories with the EAST variables listed. Now select a social problem and try to use EAST to understand it. Not so easy.] The point of EAST is that these are methods to apply after your learn about the people you intend to serve with your program and have selected the specific behavior you want to focus on with them - regardless of the theory you bring to the table. Frameworks, or heuristics, such as EAST and the 4Ps, help you make the shift from being a problem describer to a solution seeker.

For some people, EAST may seem like a good replacement for the 4Ps. Perhaps. Play with it and see how it works for you.

The 7th webinar offered by the International Social Marketing Association (iSMA) will be next Wednesday, May 14th - Using social marketing to influence social strategy.

Social Marketers need to be at the top policy and strategy development table when social interventions are being conceived if they are to be designed optimally. This webinar will explore how we can position social marketing as a first order strategy activity that is as essential in the development of social programmes as marketing is in the commercial sector. The role of social marketing in policy selection and strategy development will be examined together with ideas about how to position the benefits of social marketing to the policy and strategy process with politicians and policy makers. The session will be illustrated with some examples from around the world where social marketing is influencing social policy and strategy.

Presented May 14, 2014, by Jeff French (United Kingdom). 60 minutes. There are two live starting times to accomodate schedules around the world.

"The book goes beyond the theoretical steps of social marketing to address the larger questions of how social marketing can help solve the most urgent and complex social and public health issues of today."

If you haven't seen or read much about the book, perhaps the opening and closing paragraphs of the review will move you towards clicking on the book link and learning more about it.

[Craig] begins the book by connecting the purposes of social marketing and why people choose a profession in public health and health promotion: “How can I change the world? How can I make the world a better place?” He discusses how social marketing addresses these questions in 14 chapters, using theories, research, examples, case studies, and his extensive personal experience in social marketing for more than 25 years, both nationally and internationally. He depicts social marketing as a discipline, with a variety of viewpoints and models, and with a rich research base underlying the discipline...

Each chapter contains learning objectives, a summary, key terms, and discussion questions, which will be especially useful for academicians and trainers. Information in the book will be valuable to academicians because it presents a marketing perspective on how to approach health and social puzzles, and promotes using marketing in related research studies. For students, the book is a model for critical thinking about marketing and social change. For change agents, the book provides tools that are relevant immediately. And for managers, the book will be useful in designing, implementing, and evaluating their programs from a marketing point of view. Ultimately, the goal is for the reader to have a much broader understanding of marketing than just the four Ps, and to understand what is currently important in social marketing, what will matter for the next few years, and (most of all) what will improve the reader’s “. . . ability to innovate solutions to ‘wicked’ problems."

If you've been wondering whether to invest the time and money to read it, hopefully this may reassure you that the book is worth the hedonic opportunity costs (what fun things you could have been doing instead).

There will also be a limited number of copies on sale at the USF Social Marketing Conference 20-21 June in Clearwater Beach, FL if you'd like to meet and talk about it with me then.

You can read the entire review by clicking on the link below.

There is also a free online trial of both Health Promotion Practice and Health Education & Behavior going on now through the end of May, 2014. For more information about the free trial.

An op-ed piece in The New York Times by Ezekiel Emanuel and Andrew Steinmetz ("Finally, some optimism about obesity," 4 May 2014) suggests that we should be optimistic about our efforts in controlling obesity. They lay out the game plan for how the smoking rates in the US were reduced (advertising restrictions, prohibitions on where people could smoke, and taxation), and go on to say that the response to the obesity epidemic has been even faster than it was for tobacco use. They note that 'within a decade' of the first reports of an increase in childhood and adolescent obesity, salt and saturated fat were limited in the school lunch program (full disclosure: I was involved in the development, implementation and evaluation of that effort, aka Team Nutrition). Later, a few voluntary actions by industry, a "Call to Action" (not annual reports as with smoking) by the Surgeon General, the "Let's Move" campaign, requirements for restaurant menu labeling, and some types of local and state sales taxes on sodas round out what they call this 'nimble response.'

The response to the puzzle of the increase in obesity across most age groups may be nimble, but hardly effective. The authors embody the problem with their proposed solutions: more calorie counting, more explicit nutrition labeling, and banning advertising of junk foods to children. These education ideas may be well intended, but off the mark. What if all that had been done for tobacco control was to ban tobacco advertising to children, require prominent labeling of nicotine and tar levels on packs of cigarettes, and also have ingredients posted for each cigarette brand in places where people smoke? Would we be applauding the declines in smoking rates and lung cancer deaths? I don't think so.

A better set of solutions would start with where tobacco control became so effective - by demarketing tobacco use. Yes, you read that correctly, using marketing not to sell more cigarettes or food, but to reduce demand. How might that look for managing and reducing levels of obesity?

It may be difficult to ban food advertising, but what if all food advertising were regulated so that no images could be used in the ads or on packaging - just text and colors (not just for so-called 'kids' foods, but all foods)? What if vending/self-service machines were removed from all worksites and schools, thus reducing accessibility to foods and impulse decisions? What if food companies began to pay excise taxes on foods that in standard portion sizes (used as intended) exceeded daily standards for calories and sugars (think about the fast food offerings that this would include)? And what if we had a commitment to long-term, multi-faceted obesity control programs that went beyond information and education efforts run by lawyers and focused on increasing the price of doing business in the obesity creation marketplace? That helped communities and states reduce the ubiquity of food choices and access? And worked with organizations and industries, and not just those involved in health care, to increase incentives and opportunities for physical activity that could fit into people's lives and into organizational practices? We might have more than a nimble response, we could actually start bending the obesity curve.

Behavioral economics has emerged as a major driver of regulatory policy around the world in the past five years. Regulatory Policy and Behavioural Economics, authored by Pete Lunn, explores more than 60 examples of how behavioral science has been explicitly used to design and deliver better regulations. While pensions, tax and consumer protection in financial services and health insurance markets are the more common areas for the application of behavioral economics, public health, employment, energy conservation and charitable giving have also been successfully addressed.

Three major findings emerge from this review:

1. Consumer choices are influenced by how simply the information and range of options are presented to people, though the evidence of their effectiveness is mixed. "Much more work empirical work is needed to understand when and how the simplification of information improves decisions" (p.44).

2. People tend to choose the more convenient options, especially when they are the default ones ('nudges'). This approach seems especially relevant when immediate costs have to be considered against long-term gains - pension or retirement policies being a popular focus.

3. The importance of the attributes of choices can affect how they are weighed in consumer decision-making. Modifying these choice attributes can be applied to official warnings and advice, but also point to the need to guard against companies who downplay costs and relevant information through providing adequate regulatory guidelines for disclosure.

"It is much easier to identify behavioural problems and to devise potential solutions than it is to judge or to measure the associated impacts." Indeed, one of the conclusions of this work is the need for better research and to generate evidence for effectiveness in the specific context in which the regulations are implemented.

It is reassuring, though not explicitly stated as a social marketing precept, that the secret to the sauce of behavioral economics is in designing and delivering regulations that are relevant to consumers - not the policy makers and special interests. Mandating or supplying information that simplifies consumer decision-making, makes better options more convenient, and increases the salience of key information are goals many of us in social marketing are also working towards achieving.

The students in the advanced social marketing course I teach have been asking for guidelines about how I will be grading their various assignments, including conducting a marketing audit of an existing program or organization and developing a research plan. Because I take an expansive view of social marketing in my text, Social Marketing and Social Change, the types of outcomes that can be the focus of their projects are broader. The outcomes might include behavior change, product use or service engagement, but they could also be organizational adoption of new evidence-based screening or treatment guidelines; community engagement such as increasing public participation in, and support for, change efforts or increasing community capacity and social capital to address local issues; changes in market conditions like increased availability of healthy products to people with lower incomes or restrictions in advertising of unhealthy ones; policy changes such as organizational or statewide mandates to support active living choices; or altering the environment to provide more opportunities to engage in physical activity.

This list of questions I ask when reading their assignments also applies to how I read manuscript submissions to journals, review published papers, consider proposals for social marketing projects and funding, and yes, conduct social marketing consultations. I believe the questions are broad enough to cover many different expressions of social marketing while they also focus on critical elements that distinguish social marketing from other behavior and social change methodologies. So if you are a student, teacher, practitioner, researcher, journal editor, manuscript reviewer or grant maker who is interested in answering the question - "Am I (or are they) describing or doing social marketing well?" - or want to ask more incisive questions about the programs you direct or manage, feel free to help yourself.

Is the context of the problem described (what is the nature of the puzzle to be addressed)?

Are program objectives clear (how will success be determined)?

In planning the program, have organizational strengths and limitations been considered with respect to the opportunities and challenges present in the environment or marketplace?

Is there selection and concentration on priority groups (more than simply a ‘target audience’ that also includes potential intermediaries, stakeholders, partners critical for success)? Are they described beyond socio-demographic characteristics? Do they have Personas or another type of presentation that brings them alive as people?

Has research been conducted with priority groups? What were the major insights that were discovered?

What are the competitive behaviors, products or services from the priority group’s point-of-view?

What are the relevant behaviors, products and/or services that will be the focus of the effort (in some circumstances these could be expanded to include organizational practices, community engagement, market conditions, design changes in the built environment, policy change)? What value or benefits will be proposed by the offering(s)?

How do these offerings address price considerations from the priority group’s perspective (incentives and costs)?

How are opportunities to engage in desired behaviors, access products and/or engage with services managed?

Do messages support behavior change, adoption of new practices, community participation, market place or policy change objectives? Are relevant communication channels and technologies employed?

Is a program monitoring system in place? If yes, does it provide information about relevant program effects (for example reach and frequency of communication efforts, numbers and characteristics of product and service users, involvement of the priority group, development of engagement or relationships with people, progress towards intermediate outcomes)?

How is the program measuring outcomes of interest – progress towards behavior change objectives, adoption of new practices, public engagement and participation, changes in market conditions or the environment, and/or policy change?

Is there evidence that monitoring and evaluation data are used to improve program relevance and responsiveness to priority groups and its overall effectiveness?

Be prepared. The next large wave of tobacco control activities is about to begin, led by the FDA's 'The Real Cost' campaign (TRC). The TRC will be launching next week across the US with TV, radio, print and online components with a priority group of 12-17 year olds who are open to smoking (teens who have never smoked a cigarette but are open to trying it and those who have already smoked between 1 puff and 99 cigarettes in their lifetime and are at risk of becoming regular users). The camapign has even developed a Persona - Pete.

TRC has two behavioral objectives:

Reduce cigarette smoking initiation rates

Reduce the number of Petes who are already experimenting with cigarettes and then progress to regular use.

The campaign identifies its key messages as: • Health Consequences: A focus on consequences that are aligned with what concerns teens, e.g., cosmetic consequences like tooth loss and skin damage. The “cost” is the main theme, getting teens to think about the range of costs associated with smoking, beyond money. • Loss of Control Leading to Addiction: A focus on how cigarettes can take away the control teens are just beginning to have in their lives. This theme portrays nicotine addiction as an unwanted presence in a young person’s life.

But before you jump into action, you may also want to look at your resources and current tobacco control efforts and see how they compare to the new Best Practices for Comprehensive Tobacco Control-2014 guide from the CDC. Here's a summary of what is in the report that covers far more than just media campaigns.

Tobacco control programs should design and coordinate activities that focus on:

Preventing initiation among youth and young adults

Promoting quitting among adults and youth

Eliminating exposure to secondhand smoke

Identifying and eliminating tobacco-related disparities among population groups

State and community coalitions are essential to facilitate and sustain changes in behavior and social norms. Research has demonstrated the importance of community support and involvement at the grassroots level to achieve effective policy change, including increasing the unit price of tobacco products and creating smokefree public and private environments.

The available evidence suggests that tobacco control programs with the largest population impact integrate activities with the greatest span (including economic and regulatory approaches) and reach (number of people covered).For more about how span and reach can be integrated in tobacco control programs, see Social Marketing and Tobacco Control Policy.

Tobacco control strategies should be positioned to (a) reduce the current burden of tobacco-related diseases, (b) ensure wide dissemination of tobacco control strategies through increasing the number of stakeholders, and (c) mobilize public support and action for tobacco control.

Identifying and eliminating tobacco-related disparities among population segments should be a goal for tobacco control programs. "[T]obacco control programs and policies must be implemented in a way that achieves equitable benefits for all."

Community programs should focus on changing the knowledge, attitudes, and practices of tobacco users and nonusers and implement strategies that address how tobacco is promoted; the time, manner, and place in which tobacco is sold; and how and where tobacco is used (see The 4Ps of Demarketing Tobacco Use).

There is strong evidence for the effectiveness of communication campaigns to (a) decrease the prevalence of tobacco use, (b) increase smoking cessation, (c) increase the use of available smoking cessation services such as quitlines, and (d) decrease initiation of tobacco use among young people. See for example The Effects of Media on Health Behaviors: Evidence from Tobacco Control.

Consumer research and evaluations of media campaigns find that advertising that elicits negative emotions through graphic and personal portrayals of the health consequences of tobacco use is especially effective in motivating smokers to quit. There is also evidence that these types of advertising messages reduce tobacco use among youth and young adults. However, there have been few studies that explore the effectiveness of tobacco campaigns among population segments that bear a disproportionate burden of tobacco-related disease and death. And it is important to bear in mind that these campaigns must have the resources to support adequate reach, frequency and duration in order to be successful.

In the absence of resources for paid advertising campaigns, or in conjunction with them, local and statewide public relations efforts, including media advocacy, can effectively support key tobacco control goals. Evidence shows that these activities can lead to increased calls to a state quitline; changes in smoking knowledge, attitudes, and behavior among youth; and changes in local tobacco control policy.

The report does note that while the use of digital media, including websites, mobile apps and social network sites is becoming very popular in tobacco control programs, there is not enough evidence available yet for how effective they are in achieving tobacco control objectives or what their ideal place might be in the tobacco control program mix.

Research to develop audience insights, testing of potential concepts and strategies with priority groups, and pretesting of materials with these same groups are recommended activities in developing effective communication efforts.

Public sector tobacco control programs should not be focused on the direct provision of smoking cessation services (how to co-create these services is another topic I have touched on here). Instead, these programs should engage in efforts to reconfigure policies and healthcare systems to normalize quitting and integrate tobacco use screening and treatment in health care practice. Expanding insurance coverage and utilization of cessation services, including quitlines, should also be part of these efforts.

Statewide tobacco control surveillance systems should monitor (a) tobacco use initiation among youth and young adults, (b) quit attempts and success among adults and youth, (c) exposure to second-hand smoke, and (d) reducing disparities among population segments.

The challenge facing the FDA RTC campaign is how it will align itself with existing state and local tobacco control efforts as well as other campaigns that focus not only on tobacco issues, but other health issues (especially when they focus on teens). As the CDC guide nicely summarizes the ideal world of tobacco control:

"Linking state and community interventions creates synergistic effects, greatly increasing the effects of each comprehensive tobacco control component. Effective actions are those that reinforce one another, including: raising community awareness and mobilization efforts; developing health communication interventions; collecting, analyzing, and disseminating data; and providing cessation interventions. Evidence indicates that interventions that promote changes in social norms appear to be the most effective approach for sustained behavior change."

But the infrastructure must be in place to implement effective tobacco control programs. Among the activities that should be staffed for are:

Strategic planning to guide program efforts and resources to accomplish their goals

How can social marketing be applied by social entrepreneurs to achieve more effective, efficient, equitable and sustainable outcomes in pursuit of their vision?

For many social enterprises, the use of marketing may be limited to the products and services they offer, how they approach fundraising and public relations, or how they develop communication activities to raise awareness of, and change attitudes towards, various social problems (for example, HIV prevention, clean water, environmental sustainability and childhood obesity). They don't necessarily have a larger view of using marketing to influence behaviors that benefit individuals and communities for the greater social good. There is now some evidence that they should rethink how social marketing can improve their efforts.

Madill & Ziegler (2012) present a case study of ONE DROP, a nongovernmental organization in Canada that drives its vision of "Water for All" through integrated water and sanitation community projects around the world and by using social mobilization strategies to change water consumption and pollution behaviors in Canada. The Aqua exhibition, a multimedia event offered in several Canadian cities that is designed for 10-14 year-olds, is a key offering and is the focus of the report. As visitors exit the exhibition, they are asked to make one or more commitments to changing their behavior, from getting involved in their community to installing a device to reduce toilet water. Their methodology included key informant interviews, participatory observations of Aqua, content analysis of the ONE DROP website and Facebook pages, and a review of background documents. The results of their analysis were presented in a modified marketing audit format.1

The authors key questions and findings were:

Does One Drop through Aqua attempt to achieve behavior change? It appears that both awareness raising and behavior change are intended.

Does One Drop conduct audience research? Aqua has an established priority group (10-14 year-old children) and collects web statistics on their commitments to various behaviors (other examples included using both sides of sheets of paper, cutting back on bottled water and using environmentally friendly hygiene and cleaning products). An independent evaluation of Aqua provided evidence that Aqua achieved a strong short-term effect in the intention to commit to behavioral change. A second evaluation conducted 4 months later suggested that the organization had not been able to sustain these commitments.

Segmentation of target audiences (sic) and selection of target markets. There was no evidence in either the background documents or from the interviews that any segmentation analysis had been done. Instead, there seemed to be a post hoc analysis of the advantages and disadvantages of choosing a youth segment.

Creating an attractive and motivating exchange with the target audience? "The exchange created by One Drop through its Aqua exposition is one where consumers are being asked to change behaviors regarding water consumption and pollution (e.g., drink less bottled water). In return, they gain a world where water is a beautiful aspect of our shared world." Aqua did seem to be an attractive environment in which to make behavioral commitments, but there was weak evidence that any long-term relationship was established (despite having a website and Facebook page) to foster actual and durable behavior change.

Does the strategy attempt to use all four Ps? The answer to the question of "what is the product?" was that Aqua was the product being promoted by One Drop (note: not behavior change). Yet, one aspect of the Price element focused on the costs of the various behavioral commitments that could be made at Aqua. The second cost that was considered by the organization was the ticket price for entry into Aqua. The third element of pricing was the rental fee charged to museums for hosting the Aqua exhibit. The Place component was confined to where the Aqua exhibit was held - in all cases, science museums which fit well with the intention to attract children and their families. Finally, the Promotion of the exhibit was done jointly with each museum host through local schools as well as through the One Drop website and Facebook page.

Is careful attention paid to the competition faced by the desired behavior? "The design of the Aqua expo explicitly examines the competition by showing the results of how current polluting behaviors engaged in by both individuals and companies have resulted in ugly oil spills, as well as garbage floating in the world’s oceans and streams. It goes further in showing how continuing such behavior will result in further devastation." There was no indication of how Aqua may have been positioned against other exhibitions the museums could host, or how Aqua competed with other local attractions and special events in each city.

The authors concluded: "Although many elements of social marketing were adopted without conscious recognition that the organization was doing social marketing, it must be noted that a social marketing strategic view appears to be missing. Although One Drop intuitively utilizes many of the tools and approaches associated with social marketing, they do not strategically think it through…Perhaps, adoption of that strategic view would result in even better results in terms of achieving the desired behavior changes." [emphasis added]

While creativity and entertainment are at the heart of Aqua (the founder of ONE DROP is also the founder of Cirque du Soleil), the ability to leverage this experience to achieve behavior change and social transformation seems to be quite limited. This lack of strategic thinking can be seen in how the marketing audit uncovered the lack of clarity between Aqua and the behavioral change commitments offered at the exhibit.

If you asked me what to do to assist these social entrepreneurs in becoming more successful, it's time for two marketing plans - one for Aqua that clearly lays out the plan for its features, benefits, prices, place and promotion. But more importantly to achieve ONE DROP's primary goal is a social marketing or behavior change marketing plan - what are the behaviors, their costs and incentives, the places where they can be practiced and sustained, and how they are promoted before, during and after attendance at Aqua - that can transform this organization into a force for good (and not just one of good intentions). And I could only speculate about whether, and how, a similar lack of clear behavior change focus impacts their community projects.

I join the authors in their call for more case studies and research on the work of social entrepreneurs and how social marketing can be adopted by them to meet their social change goals. What Peter Drucker once said of business applies to social enterprises as well: "The business [social] enterprise has two - and only two - basic functions: marketing and innovation. Marketing and innovation reduce results; all the rest are costs."

1 For more information about social marketing audits, see Lefebvre, R.C. (2013). Social marketing and social change: Strategies and tools for improving health, well-being and the environment. San Francisco: Jossey-Bass (pp.290-297).

The application of social marketing to health, environmental and social issues is expanding in scope and depth. This year I was able to curate the best writing in social marketing over the past 40 years into a 6 volume series on Social Marketing. Phillip Kotler wrote about it: "This collection is a superb reference source for anyone involved in promoting better health, education, environments, and communities to start their search for great ideas and guidance." And now to continue the journey of social marketing through 2013.

I have selected 13 papers for this year from journals outside the two primary social marketing ones: Journal of Social Marketing and Social Marketing Quarterly. Click through the links to explore their content for the past year. Each of the journals contains a number of articles that could appear on my list here. However, I am assuming that many social marketers already subscribe to or review them regularly (if you don't, make that a 2014 resolution for professional development. Or better yet, join the Australian, European or International social marketing associations and get a member discount on each one).

In curating this list I have gone beyond these two disciplinary journals to give you a sense of what else is occurring in the wider world of marketing for social change. What I have tried to do with this list is sample across the many issues, topics and methods that are represented in the peer-reviewed literature to give you a broad view of what has been happening in the field over the past year. Some articles on the list were experimental studies or reviews of work on specific topics, several tackled new territory for marketing, and others honed in on specific issues that are important to the growth of the field. One of the striking changes I see in the publications this year is that many of these articles are comparison studies of an intervention that is described using social marketing benchmark criteria (for example, those developed by the NSMC). This development can help solidify the fundamentals of the field while also pointing out to editors and reviewers where the 'marketing' is in the manuscripts they recieve.

Enjoy your reading and my very best for a great 2014! This year the papers can be described as making important contributions in one of four areas:

1. Research and Review - there were several research projects reported this year that used comparison populations and rigorous application of social marketing benchmark criteria in designing their interventions. Evers at al describe a social marketing program with well-defined segments. What is notable about this study is that it is one of the few that have documented differential impacts of interventions on specific priority groups (yes, we claim that segmentation is important, but rarely do evaluations demonstrate it!). The Glasson et al study demonstrates how community-based social marketing programs can complement, and enhance the impact of, mass media campaigns (a topic that has been discussed here before). Their finding that increasing exposure to campaign elements is associated with increased likelihood to increase fruit and vegetable consumption among parents of school-aged children is also one of the few to carefully examine this crucial piece of the behavior change puzzle (see also The Team Nutrition Pilot Study (pdf)). Keller et al and Withall et al describe social marketing interventions to increase physical activity among specific population groups. Both studies employed comparison populations and reported positive results in attracting and maintaining engagement with their programs. Carins & Rundle-Thiele review 34 studies that reported using social marketing approaches to influence eating behaviors. More than half of the studies were found, using benchmark criteria, to not meet the requirements of a social marketing program. Their comparison of outcomes between programs that used fewer or more social marketing elements should become part of every social marketer's response to the question: How is social marketing different from what we usually do?

The authors combed through databases to identify studies that reported on the use of social marketing to address eating behaviors. After applying various exclusion criteria, one set of 16 papers was categorized as using social marketing as a planned consumer-oriented process (met an average of 5 predefined benchmark criteria), and a second group of 18 studies was categorized as social advertising - self-identified as using social marketing but focused on producing communication or advertising materials (mean benchmark criteria = 3). Of the total of 34 studies, 4 reported no changes and 23 reported positive changes in eating behaviors. Seven studies did not report behavioral outcomes - only 1 from the social marketing group and 6/18 social advertising studies. The proportion of studies that found change on at least some of their outcome measures was higher among social marketing compared to communication campaigns (100% v. 67 %, respectively; p=0.04). Behavioral changes were achieved in 15/16 social marketing studies and in 8/18 social advertising studies (including those that did not report behavioral outcomes at all). They conclude: 'The effectiveness of social marketing as a systematic process to change healthy eating can be enhanced. First, a number of behaviours contribute to healthy eating, and care must be taken to select which behaviour to address. Next, social marketing incorporates a mix of strategies, and relying heavily on advertising or communication should be avoided due to limited efficacy of this approach when compared with programmes utilizing more of the marketing mix. Finally, consideration must be given to the changes that can be made to social and environmental influences on behaviour as part of an integrated social marketing programme.'

The authors describe the longitudinal evaluation of a social marketing intervention that was developed to increase community awareness of asthma among older adults, and to encourage those with respiratory symptoms to seek medical advice. A pretest-posttest control group design was employed with one intervention and one comparison region. "The behavioural outcomes of the campaign give support to the segmentation of the older adult audience by recent experience of respiratory symptoms and asthma diagnosis…there were significant differences in the outcomes for the different segments. Wheezers were the most likely to take notice of campaign activities, and both target segments – Wheezers and Strugglers – were more likely to visit a health professional as a result of engaging with ‘Get Your Life Back’. The non-target segments of older adults – Breathers and Bloomers – were more likely to report taking no action after seeing the campaign."

The authors investigated the question of whether community-based social marketing strategies can augment the effects of mass media campaigns on exposure (recall of any program strategy), knowledge and fruit and vegetable consumption of parents of school-aged children. Pre- and post-intervention surveys were conducted in the intervention and comparison areas. 'The results of the present study show that the Eat It To Beat It programme achieved improvements in fruit and vegetable intake in those parents exposed to the programme. Furthermore, the results demonstrate that increased intakes of fruit and vegetables were significantly associated with increasing exposure to programme strategies…[and] emphasise the importance of local programmes that can engage the community on an ongoing basis to support and sustain the effects of larger mass-media campaigns.

A controlled trial to test a social support intervention and walking program to increase structured and leisure time physical activity among sedentary Hispanic women who were no more than 6 months postpartum. Measured outcomes included changes in body fat, fat tissue inflammation, postpartum depression (PPD), perceptions of environmental safety and resources for walking, and perceived levels of social support and exercise. "Our efforts in the design, recruitment, retention and implementation of Madres para la Salud integrated all aspects of benchmark criteria for social marketing, and demonstrate the effectiveness of such marketing procedures in recruitment and retention strategies to the cultural and contextual needs of Hispanic women."

A controlled trial to increase physical activity levels with two low income suburbs of Bristol, UK. The intervention is clearly described by segmentation criteria, marketing mix components and brand considerations. "…this study found that when compared to preexisting sessions and sessions delivered in a control area, monthly attendance patterns indicated that a reasonably well funded social marketing campaign increased recruitment into exercise sessions, maintained good levels of attendance and reasonable levels of adherence."

2. Examining Products and Services - 2013 may have been the year in which social marketers explicitly considered more than behaviors and communication starting with Thackeray et al's review of what is the product in social marketing programs and a critical examination of the influence of cigarette packaging by Stead et al. This latter study is a good example of critical social marketing - applying social marketing principles and techniques to the analysis of the marketing of socially detrimental products and services. The Zainuddin et al study with a national breast cancer screening program highlights how the Service-Dominant Logic idea of value co-production can be integrated into social marketing programs that include health and social services.

The authors identified 25 experimental, observational and survey studies that explored consumer responses to plain packaging of tobacco products on their appeal, salience and effectiveness of on-pack health warnings, and perceptions of product strength and harm. "Studies that explored the impact of package design on appeal consistently found that standardised packaging reduced the appeal of cigarettes and smoking, and was associated with perceived lower quality, poorer taste and less desirable smoker identities. Although findings were mixed, standardised packs tended to increase the salience and effectiveness of health warnings in terms of recall, attention, believability and seriousness, with effects being mediated by the warning size, type and position on pack. Pack colour was found to influence perceptions of product harm and strength, with darker coloured standardised packs generally perceived as containing stronger tasting and more harmful cigarettes than fully branded packs; lighter coloured standardised packs suggested weaker and less harmful cigarettes. Findings were largely consistent, irrespective of location and sample."

How social marketers define their product and how often tangible products and services are part of the marketing mix were explored in a systematic review of 92 social marketing intervention articles that appeared between January 1999 and October 2009. All but 1 program focused on behavior change. The most common behaviors were: go see a health care provider to receive a checkup or screening (n = 15); use insecticide treated nets (n = 8); use a form of contraception (n = 8); take a multivitamin or folic acid supplement (n = 5); make better food choices (n = 8); and be more physically active (n = 6). Seven programs focused on stopping a negative behavior, such as not smoking or drinking, or sharing needles."Only 17 articles (18.5%) used the 4Ps or marketing mix-related terminology. Only these studies were analyzed to answer the question about how social marketers define the product... Six of the 17 studies identified the product as an item (35.3%), three as a service (17.6%), and seven as a behavior or focus on awareness (41.1%), with one identifying it as the benefit (5.9%)…The absence of marketing terminology within a research article makes it difficult to determine if the researchers are implementing a marketing strategy or just a general behavior change strategy and labeling it social marketing."

Consumers as active participants and creators of value, rather than as passive recipients of programs and services, is emerging as a new perspective in marketing circles. This study tests this approach with a study of value creation and service outcomes (satisfaction and behavioral intentions) for a national breast cancer screening program. They provide evidence that "cancer screening services that seek satisfied customers…need to ensure that the value customers perceive encompasses feeling protected, happy, calm and safe, as well as providing consistent screening quality that is reliable and at an acceptable technical standard."

3. Equity in outcomes - Social marketing can become a leader in social change circles by focusing on how its approach can lead to more equitable reach, effectiveness, health status and well-being. This issue received attention in at least two evaluations of social franchising programs this year. Chakraborty et al describe how to assess equity in health outcomes by examining data from three social marketing programs focused on HIV prevention, family planning and malaria control. They go on to discuss how these results can then be used to better calibrate and concentrate resources to enable positive change among the most disadvantaged populations. Montagu et al use national economic data to assess how well a social franchise network cares for poorer people in both rural and urban areas in Myanmar, a type of analysis many other national prorgams should consider in their evaluations.

As many social marketing programs are intended to reach the poor, these authors argue that is is essential for social marketing programs to 'monitor the health equity of their programs and improve targeting when the poor are not being reached.' Using cross-sectional surveys from three surveys, the investigators calculated wealth quintiles and concentration indices (the magnitude of socioeconomic inequality) to measure the distribution of health outcomes by wealth and to assess whether interventions had reached the poor. Program-specific results were found for reach and adoption of health practices among the wealthy and poor (use of bed nets, IUDs and condoms). "…[S]ocial marketers simultaneously seek both health impact and market growth, in order to promote long-term access, availability, use, and ultimately, impact of the promoted health product or service. To successfully expand the market, these organizations need to ensure that intervention strategies encompass the different segments of the market - public, socially marketed, or commercial - and appropriately target the individuals they serve, based on socioeconomic status."

This study explores whether the benefits of a branded social franchise network that include increasing case detection and higher treatment completion rates for tuberculosis (TB) directly-observed-therapy (DOTs) are shared equitably. A comparison of national national TB prevalence data with patient data from Sun Quality Health (SQH) providers found that "In rural areas the SQH franchise providers are caring for patients that are not statistically different in wealth than the general population of TB-infected individuals. In urban areas, SQH clinics are treating patients that are poorer than the general infected population. These findings suggest that franchises are successfully reaching low-income TB patients in urban areas, but could improve targeting of lower socioeconomic groups in rural areas."

4. Special topics - Several publications stood out to me for their focus on topics that are not discussed enough in social marketing. Evans-Lacko et al review the impact of a national campaign to change attitudes towards people with mental illness. The authors note the important features of this campaign were a focus on population segments and behavioral outcomes, though it can be debated whether the campaign implementation was very different from a well-done integrated communication effort. As you may already have noted, segmentation was highly visible in many research reports this year. A useful addition to discussions about segmentation (The first critical decision in social marketing) is from Newton et al who carefully evaluate the claims of the usefulness of segmentation, apply ethical theory to examine the arguments for and against it, and use a case study to also demonstrate the impacts of NOT segmenting in public health programs. Finally, Turk et al dispense with the idea that all formative research for program planning must be laborious, lengthy and costly with their description of the use of the rapid assessment and response methodology in planning a physical activity in Tonga.

The TTC program aimed to make significant improvements across England in public attitudes and to achieve less discriminatory behavior in relation to people with mental illness. The priority group was identified through research as ‘subconscious stigmatizers’: people who do not recognize that discrimination against people with mental health problems happens, or how their actions might contribute to this. Campaign elements included mass and social media, with tips for fighting stigma and stories from people with mental illness on the TTC website. The behavioral outcomes, which the authors claim is a first for an anti-stigma campaign, included starting a conversation about mental health with a friend or co-worker, to helping organize a local event aimed at engaging the community or organizations in fighting stigma and discrimination against people with mental health problems. "Campaign awareness and social contact [with someone who had a mental illness] were the most consistent positive predictors of better knowledge, attitudes and intended behavior towards people with mental illness."

The authors identify two ethical questions about the use of segmentation in social marketing contexts: (i) can the use of segmentation be ethically justified; and (ii) if segmentation can be justified, what approach should be used to select the groups that are included or excluded from the priority group? They identify three perspectives on the answers to these questions. First are the people who advocate for non-segmented, population-wide programs as a method to be egalitarian and nondiscriminatory. The second group argue for segmentation to serve the needs of the most vulnerable members of a society. A third group, that they refer to as 'consequentialists,' support segmentation when it demonstrably achieves the greatest good for the largest number of people. Using Integrative Social Contracts Theory and Theory of Just Health Care, the authors evaluate these different perspectives on the use of segmentation through the use of a case study of increasing awareness and support for the use of antiretroviral therapy in Kenya. They conclude that both theoretical models '…support the ethics of segmentation in health-related social marketing contexts.' Their findings also provide support for the idea that NOT using segmentation has ethical implications as well - in this case, by strengthening preexisting asymmetries in health knowledge that would disadvantage citizens with limited education.

The authors describe the application of a rapid assessment and response (RAR) methodology to identify priority segments for a physical activity program in Tonga. The elicitation research encompassed qualitative fieldwork approaches, including semistructured interviews with key informants (including government and local officials, NGO and religious leaders, and representatives from the media and private sector partners) and focus group discussions with program beneficiaries (women and their male partners).The authors suggest that RAR may be especially useful as a practical approach to data collection and rapid mobilization in low resource environments. "Essential insights for the strategy design were identified from key informants, as well as ensuring future engagement of these stakeholders into the strategy."

I have linked to the full text whenever possible [html and/or pdf available]. In other cases, the link will be to the Abstract. Please contact the author of a paper with any requests for a full reprint (pdf).

And as a bonus reading in social marketing, if you have not already heard about or read my textbook on social marketing and social change, you can get started with some excerpts here. Please consider buying the book, and applying and sharing the ideas and techniques in it to help solve your health and social puzzles in 2014. As Bill Novelli put it: “This is it -- the comprehensive, brainy road map for tackling wicked social problems. It’s all right here: how to create and innovate, build and implement, manage and measure, scale up and sustain programs that go well beyond influencing individual behaviors, all the way to broad social change in a world that needs the help.”

The public health professional core competencies, in my opinion, have not adequately reflected or prepared people for critical elements of their jobs-to-be-done: improving health behaviors of individuals and in communities, increasing the adoption and use of evidence-based practices by public health and allied organizations, and promoting and strengthening environmental and policy changes to improve and sustain public health. The Council on Linkages Between Academia and Public Health Practice (Council on Linkages) is in the process of reviewing and revising the current Core Competencies for public health professionals. As part of this process, the Council on Linkages is collecting feedback on the Core Competencies from the public health community. Please consider the following observations and suggestions for how they could be improved to be more relevant to the practice of public health as I have observed and participated in it over the past 30 years. If you agree with these, and have other opinions about competencies for public health professionals, you have until December 31st to submit them. Feel free to copy and paste these comments, edit them, and add to them in the comments section of their feedback form.

In reviewing the current core competences, only three - rather weak - competencies touch on the jobs-to-be-done by public health professionals as outlined above: 2A6 - 2B7 - 2B8: participates, develops and implements plans and programs consistent with policies (Policy Development/Program Planning Skills). A second one in that domain, 2A8 - 2B9 - 2C10, mentions the need for program monitoring and evaluation skills. Finally, 3A4 -3B4 - 3C4 address using a variety of approaches to disseminate public health information (e.g., social networks, media, blogs). These isolated competencies stand in marked contrast to the more detailed 6-7 'Communication skills' and an equal number of 'Cultural competency skills' currently identified in the Core Competencies.

Despite the existence of the Core Competencies and others (for example, for MPH and DrPH programs), there have been few investigations of what is needed for success in the context of practice, not academics. And when one turns to whether characteristics of the public health workforce are associated with improved effectiveness and changes in population health outcomes, a recent survey of the public health workforce literature found no published study that had investigated the question (Beck & Boulton, 2012). My point here is that we need to pay more attention to what is needed in the real world of public health practice; not theories and fashions.

The needs for competencies in communication and marketing in the public health workforce have been consistently voiced. In the context of reducing health disparities, Golding & Rubin (2011) noted that the success of any expansion of programs and services to close gaps in health status rests on the effectiveness of the information and communication that is provided by health communicators and health marketers. In their survey of members of the National Public Health Information Coalition, 66% of respondents identified the planning, development and implementation of interventions, and marketing and advertising as major job responsibilities. The leading training topic survey respondents identified for themselves – and for other staff in their state or local health department – was to “understand how to tailor and target campaigns that will improve the well-being of diverse individuals and communities.” Social marketing has been identified as part of the continuing education competencies for the currently employed public health education workforce, and public health leadership training initiatives include marketing as part of their curriculum (Allegrante, Moon, Auld & Gebbie, 2000; Hawley, Romain, Molgaar & Kabler, 2011). Harris et al (2012) note that the marketing discipline can significantly contribute to the frameworks that are used, and the dissemination and implementation strategies that are selected, to bring more evidence to the daily practice of public health.

Consistent with these views, Healthy People 2020 included social marketing among the objectives for the Nation to achieve over the course of the next decade. Specifically, Healthy People 2020 Objectives HC/HIT – 13.2 and HC/HIT-13.3 are:

Increase the proportion of schools of public health and accredited master of public health (MPH) programs that offer one or more courses in social marketing.

Increase the proportion of schools of public health and accredited master of public health (MPH) programs that offer workforce development activities in social marketing for public health practitioners.

[13.1] Increase the number of State health departments that report using social marketing in health promotion and disease prevention programs.

Social marketing is a systematic process for developing behavior and social change programs with documented successes for many public health issues, across many different population groups and in many different contexts (see Lefebvre, 2013). The strategies and tools, discussed below, are a foundation for the best in public health change programs, whether it is truth®, Verb™ or the current TIPS campaign. Indeed, when read alongside a social marketing textbook such as Lefebvre (2013), the discussion of the "six components necessary for public health intervention" by the Director of the CDC (Frieden, 2014) includes many of the key features and ideas that characterize a marketing orientation and approach to public health.

Tier 1: Entry level professionalsExplains and differentiates a social marketing approach and demonstrates the appropriate application of social marketing approaches and tools (audience segmentation, behavior selection, consumer research, application of evidence-based theories and models, use of integrated marketing strategies, behavior change evaluation) to support development of health promotion and disease prevention programs and policies.

Tier 2: Individuals with management and/or supervisory responsibilitiesManages and leads the development of health promotion and disease prevention programs and policies using a social marketing strategic planning approach and community input.

Tier 3: Senior managers and/or leadersCommunicates, encourages and ensures professional, organizational and community support for the ethical development of health promotion and disease prevention programs and policies based on social marketing approaches.

These competencies might be considered for inclusion under a broader domain of competencies.

I propose to the Council to consider what if they developed a separate set of competencies under the domain of Public Health Change skills (or behavior, community and social change skills)? For people in the field, this is what they have to do to be successful. And for many students entering public health, this is what they want to do, change the world - or at least their corner of it. They should be prepared by public health education and training programs to be as good as they can be at it. For a more articulated vision of what a set of competencies for Public Health Change Skills could be, I propose starting with:

1. Describe social marketing to colleagues and other professionals, differentiate it from other approaches to behavior and social change, advocate for its appropriate application to social policy development and implementation.

2. Work with colleagues and stakeholders to identify community or national priorities and identify those to which a social marketing approach may be usefully applied.

3. Identify affected populations and select appropriate segments to give the greatest priority to in program planning.

5. Design and conduct a situational analysis, evidence reviews and formative research needed to understand the perspectives on the problem and its possible solutions by people affected by it and stakeholders, and identify their perceived value (benefits) for the change objective as compared to the alternatives.

6. Apply appropriate behavioral and social science theories and models to the development of a framework to describe the problem and its potential solution.

7. Analyze, synthesize and apply theory, evidence and research insights to create an integrated marketing strategy and plan.

8. Develop and test the relevance and potential effectiveness of marketing strategies (e.g., concepts and approaches) and tools (e.g., products, services and messages) with representatives of priority groups and stakeholders.

9. Implement, manage and lead social marketing interventions.

10. Design and implement a program evaluation plan, including a monitoring system to assure programs are on track to achieve goals.

11. Apply ethical principles to conducting research, and developing and implementing a social marketing plan.

12. Communicate the results of the program and its evaluation to colleagues, stakeholders, communities and other relevant organizations and groups.

Again, we can debate whether 'social marketing' needs to be incorporated into every competency listed above (for example, #1, 2, 9 and 11). However, I think few seasoned public health program planners would argue against the importance of each of these items in any well developed and implemented public health program - whether it is aimed at individual, organizational or policy change.

Finally, I recommend that the framers of the Council on Linkages' revised competencies give special attention to their role in fostering evidence-based public health. As Brownson, Fielding & Maylahn (2009) have noted, the development of an evidence-based approach to public health practice involves more than a knowledge of the science of what works with what identified problem, when, under what circumstances and with whom. There is also a need to have frameworks that can serve to translate this scientific knowledge into effective, efficient, equitable and sustainable programs in real-world settings. And there must also be broad and consistent dissemination and implementation of proven interventions at both the state and local level of public health practice. I believe that incorporating the concepts and tools of social marketing into the next version of public health competencies is a significant step in that direction.

A big step was taken in that direction today as social marketing shifted from a good idea in public health to a measurable objective for improving the nation's health. The Federal Interagency Workgroup for National Health Objectives for 2020 met and approved proposed changes to the Health Communication & Health Information Technology objective that read "Increase the proportion of State health departments that report using social marketing in health promotion and disease prevention programs."

The new objective is: Increase the number of State health departments that report using social marketing in health promotion and disease prevention programs. The Workgroup also approved moving the objective from its previous 'developmental' status to a measurable one. But what is most exciting for me is the proposed target for 2020: 50 state health departments.

Social marketing practice in health departments was measured by asking managers of health promotion and disease prevention programs to endorse the following items using a scale ranging from 'None or almost none" to "All of our programs."

When designing our programs, we focus on understanding our priority audiences’ lives and behavior as much as possible.

We identify specific, measurable behaviors that the program is focused on influencing in our priority audiences.

We refer to social and behavioral science theories to inform program design and implementation.

We conduct audience research to understand what moves and motivates them, including ‘who’ and ‘what’ influence the targeted behavior.

Our programs incorporate the costs and benefits our audience perceives in changing or giving up the targeted behavior.

We identify and incorporate factors that compete for the time and attention of audiences whose behavior we seek to influence.

We identify priority audience segments that have common characteristics and then tailor programs appropriately.

We use all elements of the marketing mix – product, price, place and promotion – to influence the targeted behavior.

At baseline, 8 state health departments met all of the criteria for at least one of their programs (more details are available in the presentation and publication). And no, using Facebook, Twitter or other social media marketing tools did not count - though there's no reason to not include them in your program mix. Just follow the other seven too.

The challenge for the field in the US is clear - accelerate adoption from 8 to 50 in the next 5-7 years. This means not only promoting the objective to our colleagues in the public sector, but also designing new training and education products and services for students and practitioners, incorporating social marketing approaches into emerging public health policies and practices (for example, educational and professional competencies), identifying how and where these 8 features are compatible with evidence-based and innovative public health practices, providing exemplars that others can model and adapt to their unique circumstances, and not surrendering the position that social marketing is about serving people, not using technologies.

I have been in many classes, meeting rooms, webinars and workshops explaining the principles of social marketing. Then, about 3 years ago, an editor approached me about writing a book about it. And it turned into a love-hate endeavor. I loved the idea about writing it all down in one place, and hated that there was still more to say. One result of the process of writing the book was to help me focus on what I consider the most important things for someone to know about the field. It runs 504 pages before the references start.

Since the book was published I have been invited to talk about social marketing in several diferent venues. A recent one was in Brunei where we had a week-long workshop on social marketing and I was invited to lecture at the Universiti Brunei Darussalam. The challenge: how do I distill social marketing into 45 minutes for people who are new to the topic - and aren't expecting to hear about social media marketing?

The slides and talking points I used in this presentation are available at Slideshare and are free for you to download for your own use in classes, lunch and learns, workshops or in any other way you find fits your needs. It begins with re-conceptualizing social problems as being wicked puzzles that require searches for solutions with the people they are intended to serve. The international consensus definition of social marketing is presented, followed by 10 principles:

You will notice that some of the pictures have a very local, or Brunei, character to them. I find some of them work well with other groups because they portray things that are not their usual perceptions of life - they capture people's attention and can start other conversations. However, you can also swap them out for your own pictures of the realities of the people you are talking with about social marketing (isn't that the whole idea?).

And now for the shameless plug: It's a great time of year to catch up with what is tested and new in social marketing. The reviews say it all. Buy a book, or give one to your favorite social marketer or social entrepreneur, to start the new year with a different perspective and new insights for your work.

Effective communication is an essential component in the mix of strategies used to effect behavior change in regard to healthy eating. But are nutrition educators using all the behavior change tools? Are we really communicating effectively? Is our communication passionate enough and inspired enough to be heard? How do we increase the likelihood of improving healthy nutrition behaviors? With so many voices and choices out there in so many mediums (i.e. social media, grocery and food packaging advertising, television commercials, radio, etc) we have constant competition. This topic is sure to get nutrition educators thinking about how they currently communicate and to consider new avenues and strategies for their programs.

The session is for people who are looking to disrupt their usual way of doing their work. Participants will be exposed to marketing, behavioral economics, behavior/social change and social media theory and examples. The ideas and tools are designed to stimulate innovative approaches to nutrition education.

Learning Objectives a. Identify differences in the approach to using social media in communication programs. b. Specify why communication is only part of the solution (what are other pieces?).c. Apply behavioral economics principles to nutrition education programs. d. Understand the importance of people-centered and place-based programs for improving nutrition behaviors.

Over 600 locations tuned into the 50 minutes of my presentation and 30 minutes of Q&A. Some of the countries outside the US that were there included Canada, Columbia, Czech Republic, Spain, Indonesia, Israel, Italy, Malta, Mexico, Pakistan, Romania, Somalia, Turkey and Uganda. You can register to hear the session and receive the slide deck.

There were several questions that we didn't have time to discuss during the webinar. They will be the focus of my next post. Catch up on the discussion and join me here next week.

Social Marketing seeks to develop and integrate marketing concepts with other approaches to influence behaviours that benefit individuals and communities for the greater social good.

Social Marketing practice is guided by ethical principles. It seeks to integrate research, best practice, theory, audience and partnership insight, to inform the delivery of competition sensitive and segmented social change programmes that are effective, efficient, equitable and sustainable.

This definition is the result of an on-going and inclusive process that began in February 2012. Members of the organizations were polled to suggest principles to be a foundation for a definition; online voting was then done by 167 members as to which principles they thought were 'essential' or 'important' to a definition of social marketing; and a working group of 14 representatives from the three organizations used these inputs to draft the final document with review and input from their respective Board members.

Five considerations were taken into account in developing the definition:

1. It was recognized that the definition would be a consensus statement; it would not seek to limit or curtail debate about the nature of social marketing. The consensus definition's purpose is to enable the supporting associations to develop a common narrative about the nature of social marketing that will assist us in furthering our collective aim of capturing and spreading good practice.

2. The definition should focus on both the purpose and nature of social marketing practice.

3. It should be as short and succinct as possible.

4. The definition should be as unambiguous as possible and it should be capable of translation into languages other than English without loss of its substantive meaning.

5. The definition should be subject to on-going refinement to reflect the dynamic and developing nature of social marketing theory and practice.

Phil Dusenberry, the former chairman of the advertising agency BBDO North America, wrote that marketers relied on consumer research more than any other profession. He went on to say: “you need to learn something you don’t already know . . . so much of what poses for research is little more than people seeking information that confirms their biases, their goals, their inclinations, and their decisions. It has nothing to do with acquiring new information."

Too much of our own 'satisfaction research' only reinforces how smart we are in constructing our questions. These questions may be based on elegant and popular theories of change, can trace their lineage to a long line of previous research evidence, and be posed to people in objective ways in controlled environments to rule out extraneous variables. But what do the answers or data teach us? You don't have to look any further than today's headlines that "obesity among 2-4 year-olds in the US is declining!" Well…maybe, in some states. Unfortunately, as the research report the headlines are based on owns up to: "The specific factors that might have contributed to the differential changes in obesity prevalence by state could not be readily identified."

Public health surveillance systems, and epidemiology more broadly, are good at describing problems. However, they provide little if any insight into how to solve the problem they describe. I devote two chapters of my book to using different research methods to search for insights to solve problems. My belief is that not knowing how to conduct 'solution seeking' research is a significant constraint for people trying to improve public health and social conditions.

Let's take the example of aging-in-place, an important area in the aging and health space. Suppose you wanted to improve the quality-of-life and extend the time people could live safely, independently, and comfortably in their homes. What would you do first?

Hopefully, you thought about "research" or "talk with them." Let's go from there.

What questions would you ask them… would you want to do a survey… conduct focus groups… visit senior centers?

Or, might you do in-depth interviews with seniors in their homes… interview their caregivers… ask seniors to give you a guided tour of their home and describe a typical day in their life?

Now, which of those approaches might help you better describe the problems associated with aging-in-place? Which ones would give you a better understanding, empathy with seniors and their caregivers, and insight into how to address the problems of aging-in-place?

How can you shift yourself, and the people and organizations around you, from designing and using research to describe problems to seeking solutions to solve them?

Try asking people 'why" - not once, but up to five times. That will cut down on the number of questions you can ask people to describe a problem and shift you into listening to how they experience it.

Resist the default option of focus groups to talk about the problem and instead design research to search for solutions to it. Solutions, by the way, are something many people you call your 'target audience' are happy to explore with you.

Understand people's jobs-to-be-done, motivation and values instead of getting caught up in assessing knowledge, attitudes and barriers according to the latest theory or research study.

Begin with understanding the context and environment rather than assuming there's something 'wrong' with the people you intend to serve.

And then, perhaps, your research about aging-in-place work might lead to a solution platform that sounds like this (from frog healthcare group):

Enable seniors in their ongoing quest to define and share themselves, their values, their je ne sais quois, with others.

Support their abilities and expose them to new interests to keep them busy, vital members of society.

Help them retain a sense of sovereignty, independence and control by enabling and supporting daily routine.

Help them stay mentally and physically active through supporting and enhancing everyday events.

What we need is more research for solution seekers; the world already has plenty of it for problem describers.

How do we solve the mystery of crossing the bridge from academia and scholarship to having passion and making a dent in the world? One arena in which that mystery is addressed in a conscious and deliberate fashion is in Transformative Consumer Research (TCR), something I have covered on this blog as well as in my book. As a number of us are preparing for our session at the Association of Consumer Research Conference - "Making a Difference in Different Ways: Unleashing the Power of Collaborative Research Teams to Enhance Consumer Well-being,” Ron Hill passed along something he called "A Day in the Life of a TCR Scholar." It tells his story of crossing the bridge and I think it gets to many key issues in solving the mystery. Ron graciously allowed me to publish it here.

I
have had the opportunity to work with a variety of professionals and interested
parties in homeless shelters, community action agencies, prisons, and other
contexts that may benefit from our expertise and service. There are several lessons
that I learned during these experiences that continue to serve me today. First,
forget about your education, teaching, and resulting status within the academy;
it likely serves you well in some environments but it might not do so in an
impoverished neighborhood, juvenile delinquent lockdown facility, or maximum
security prison. Thus, you need to enter the field with humility and openness
to what you can do to serve their needs rather than assuming that they are
there to help you advance your reputation in the field. Second, enter this
environment with a “beginner’s mind” as if each experience was new and you were
unable to use past memories to define what is happening in the present. If you
do not, it is likely that your
perceptions and values will be used to define the field in ways that do not
fully capture the lives of the people you interact with over time.

Third, try to find a locally
appropriate role to support your efforts, one that gives purpose to your
presence and serves the community where you now reside. Sometimes your expertise
or academic background, such as tutoring teenagers in a poor public school
system, comes into play and is actually useful. Other times, like when they
need a cook or server in a food kitchen, you may have to put aside your ego and
realize that you are only capable of the most mundane tasks. Fourth, forget
what you heard in graduate school about “objective” versus “subjective”
research. Only the most hardened among us can enter environments like homeless
shelters for women and children and not be moved. Instead, allow yourself the
luxury of feeling deeply and experiencing completely the range of emotions
associated with their lives. You will have much richer data and be able to tell
a more compelling story. Some may believe you have become an advocate … so
what? It is the price we pay for embracing the humanness of those we study.

Fourth, forget about your proposed
schedule. Six months in the field, followed by three months of data analysis,
followed by … You may have days, like I had recently, when you wait a full hour
before you are allowed to proceed 100 feet, only to find that the men you came
to see are in lockdown for a random search. In this particular case, it took
over eighteen months to put the first paper together, and some of my time is
still dedicated to them. Instead of interviews or other forms of “relevant”
data collection, I have been asked by incarcerated men to help their spouses
write a resume, their children navigate college entrance requirements, their
former neighbors develop licit opportunities for young children to earn money, and
their attorneys come up with new ways of seeking release. In the final
analysis, it is not whether these investigations result in publication. Some
will and some will not. It is about impacting lives, changing their courses for
the better, and loving our neighbor. My motto has been “Changing the world one
article at a time.” Come live the dream!

[Ed Note]

Ronald Paul Hill, Ph.D., is the Richard
J. and Barbara Naclerio Endowed Chairholder, Villanova School of Business. He has authored nearly 200 journal articles,
book chapters, and conference papers on topics that include impoverished consumer
behavior, marketing ethics, corporate social responsibility, and public policy. He was the Editor of the Journal of Public Policy and Marketing until June 2012. His recent awards include: 2012 Williams-Qualls-Spratlen Multicultural Mentoring Award
of Excellence, 2012 Villanova University Outstanding Faculty Research
Award, and 2010 Pollay Prize for Excellence in the Study of Marketing in the
Public Interest.

A new article on mobile health technology evaluation presents the findings and recommendations of a group of experts gathered together by the National Institutes of Health in the mHealth Evidence Workshop (disclosure: I was one of the participants and authors).

Although the discussions at the meeting were cross-cutting, the areas we covered fell into three areas: (1) evaluating assessments; (2) evaluating interventions; and (3) reshaping evidence generation using mHealth. The article goes into detail on each of these issues. I'll highlight just a few of the ideas here.

First, to acknowledge what is the obvious to many of us in mHealth.
"Creative use of new mobile health information and sensing technologies (mHealth) has the potential to reduce the cost of health care and improve health research and outcomes. These technologies can support continuous health monitoring at both the individual and population level, encourage healthy behaviors to prevent or reduce health problems, support chronic disease self-management, enhance provider knowledge, reduce the number of healthcare visits, and provide personalized, localized, and on-demand interventions in ways previously unimaginable." The continuum of mHealth tools graphic effectively pulls these ideas together.[Note: you can click on any of these images to enlarge them.]

Evaluating mHealth assessments require us to consider the reliability and validity of the measurement tools we utilize and the quality of the data they provide. The next table illustrates some of the reliability and validity issues we touched on in the workshop.
Especially when there is the rapid evolution of mHealth device technologies, reliability and validity can as likely degrade as improve as new versions appear. We particularly pointed out that research is needed to better understand the many possible confounding and intervening variables that can affect collecting time-intensive data in real-world settings, from self-quantifiers to patients being monitored at home for signs of congestive heart failure or to assure their general safety and well-being (as in aging-in-place studies). mHealth devices are frequently used by individuals with little training, or in situations where comfort and convenience are paramount. What are the trade-offs, and which ones are justifiable from patient, provider, researcher and ethical perspectives?

The participants noted that there are many unanswered questions about the appropriate use of research designs in mHealth and, alternatively, how mHealth might improve or lead to new research methods. For example, can obtaining multiple repeated measures on a few participants, rather than a few measures on many participants, reduce the size of clinical trials and make conventional research designs more efficient (i.e, quicker, cheaper, and more viable for the rapidly moving technology-based mHealth in terms of time and recruitment)?

As shown in this third table, there are many different research designs that can be employed in mHealth, the randomized clinical trial (RCT) being only one, and sometimes perhaps not the best, option. Among the alternatives suggested by participants are the continuous evaluation of evolving interventions (CEEI) for testing mHealth interventions; the multiphase optimization strategy (MOST) to assess tailoring and intervention optimization in treatment research; and the sequential multiple assignment randomized trial (SMART) might be used where individuals are randomly assigned to various intervention choices over time, rather than staying on one protocol.

We also looked at how mHealth is already reshaping evidence generation. For example, mobile technologies can provide data at very high sampling rates (e.g., 10–500 times per second) that support the quantification of phenomena (e.g., physical activity, physiological changes) that previously were poorly understood because of intermittent and limited measurement. Moving on from data collection to data capture, the data density created by these high sampling rates requires data processing methods not commonly used in health research. Finally, data analysis can be conducted more quickly, sometimes in real time, given that direct contact with participants is no longer necessary. mHealth can facilitate remote research recruitment and potentially reduce the frequency, and consequently, the burden and costs of face-to-face interactions.

A common vision of the workshop participants was using mHealth technologies to generate comprehensive data sets and information fusion. mHealth provides an opportunity to gather data from multiple sensors and modalities including divergent physiologic, behavioral, environmental, biological, and self-reported factors that can be simultaneously linked to other indicators of social and environmental context. In addition, they can be linked to healthcare system and payer data at either the individual or population level.

In the concluding section, we note that "Although these methodologic challenges present exciting new opportunities for scientific innovation, the marketplace and consumers are not waiting for scientific validation. This workshop endorsed the need for timely and increased efforts in mHealth research and for a new transdisciplinary scientific discipline incorporating medicine, engineering, psychology, public health, social science, and computer science."

So What?

Are
we developing reliable and valid methods to do what we aspire to and promote for mHealth?
Demonstrating their relative value through rigorous testing of methods,
processes and outcomes? Showing that they improve the effectiveness, quality, equity
and efficiency of promoting and improving health and health care -
especially when compared with some of the alternatives? These are the
major questions we should be asking of mHealth. Not - is it cool...have they done a TED talk about it...is
the guy rich...can I have one too? (OK, may be I'm simplifying that...a
little).

You can find the entire article by clicking on the title in the reference.